Understanding Why Your CTP Claim Might Be Denied
If your CTP claim has been denied by an insurer in Auburn, New South Wales, it is important to understand that denial does not necessarily mean your claim is invalid. Insurers may deny claims on grounds such as lack of liability, dispute over injury severity, or failure to meet statutory requirements under the Motor Accident Injuries Act 2017. The denial may relate to whether the accident occurred, whether you were injured as a result, or whether your injuries meet the threshold for damages. In many cases, the denial is not final and can be challenged through formal dispute processes. You have rights under NSW law to seek a review of the decision and to request a determination from the State Insurance Regulatory Authority (SIRA).
What You Should Do Immediately After a Denial
The first step after receiving a denial is to obtain a written explanation from the insurer. This should detail the specific reasons for the refusal, including any assessment of liability, injury classification, or compliance with procedural requirements. Do not ignore the letter. You must act within the time limits set by law. Gather all relevant evidence, including medical records, photographs of the scene or vehicle damage, witness contact details, and any correspondence with the insurer. If you were treated by a medical practitioner, obtain a copy of your treatment notes and a certificate of injury. These documents may help establish that your injuries were caused by the motor accident and that you are entitled to benefits.
Evidence That Can Help Challenge a Denial
SIRA recognises that the strength of a claim depends on the quality and consistency of evidence. Key evidence includes:
- A medical certificate from a registered medical practitioner confirming the injury and its link to the accident.
- A report from a specialist, such as a neurologist or physiotherapist, if your injury involves ongoing pain, mobility issues, or neurological symptoms.
- A police report or accident report, if one was filed at the scene or later.
- Photographs taken at the scene, showing vehicle positions, damage, road conditions, or signage.
- Witness statements, including contact details and a brief account of what they observed.
- Records of lost income, if you are claiming weekly income payments.
If your injury includes symptoms such as neck pain, back pain, or numbness, and your medical report indicates signs of nerve involvement, this may support a claim that the injury is not merely soft tissue. The Motor Accident Guidelines clarify that a spinal nerve-root injury with neurological signs, such as altered reflexes, muscle weakness, or sensory changes, may still qualify as a threshold injury even if radiculopathy is not present.
Dispute and Review Options Under NSW Law
If your claim is denied, you can apply to SIRA for a review. SIRA is the independent authority responsible for administering the NSW CTP scheme. You may request a review of the insurer’s decision on liability, the amount of benefits, or the classification of your injury. The review process is free and can be initiated online through the SIRA website. You must submit your request within 12 months of the insurer’s decision, or within 12 months of the date you first became aware of the denial.
SIRA may also assist in resolving disputes through mediation. This is a voluntary process where a neutral third party helps you and the insurer reach an agreement. Mediation can be faster and less adversarial than formal review. If the dispute proceeds to formal review, SIRA will assess the evidence and make a binding determination. You are not required to have a solicitor to participate, but independent legal advice may help you understand your rights and options.
Time Limits for Challenging a Denial
Time is critical. You must begin the dispute process within 12 months of receiving the insurer’s denial letter. This deadline is strict and cannot be extended unless exceptional circumstances apply. The 12-month period starts from the date of the letter, not the date you received it. If you miss the deadline, you may lose the right to claim benefits under the CTP scheme. In some cases, a claim may still be considered if you can demonstrate that you were unable to act due to mental incapacity, serious illness, or a misunderstanding of the law. However, these are limited exceptions and must be supported by evidence.
What You Should Ask Your Insurer When a Claim Is Denied
When you receive a denial, ask the insurer to provide:
- A full written statement of the reasons for the refusal.
- A copy of any internal assessment or medical report used to make the decision.
- Confirmation of whether they have accepted liability for the accident.
- The name and contact details of the claims officer handling your case.
If the insurer claims you have a threshold injury but you believe your injuries are more serious, ask for a copy of the impairment assessment and the criteria used. You may also request a second opinion from a medical practitioner approved under the CTP scheme.
Hypothetical Example: A Claim Denied in Auburn
A pedestrian in Auburn was struck by a car while crossing a marked crossing at a traffic light. The driver claimed they did not see the pedestrian. The insurer denied the claim, stating there was no evidence of impact and no witness to confirm the pedestrian was hit. The injured person had sustained a back injury and was treated by a physiotherapist. They provided a medical certificate confirming the injury was consistent with a motor vehicle impact. They also submitted a photograph of the vehicle’s position and a statement from a nearby shopkeeper who saw the incident. The claim was later reviewed by SIRA, which found that the evidence supported a finding of liability and that the injury met the threshold for damages. The claim was approved for treatment and care benefits and weekly income payments.
Next Steps: Seek Guidance Before Acting
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.